Benchmarking and quality improvement: the Harvard Emergency Department Quality Study

Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices

BACKGROUND

Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention for rigorous development methodologies, it remains unclear what contribution CPGs make to quality improvement.

AIM

This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices.

METHODS

The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow-up interviews to examine how different quality aspects were considered during development.

RESULTS

The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices.

CONCLUSION

Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge.

Process improvement approaches in emergency departments: a review of the current knowledge

Purpose

The healthcare system has been under pressure to provide timely and quality healthcare. The influx of patients in the emergency departments (EDs) is testing the capacity of the system to its limit. In order to increase EDs' capacity and performance, healthcare managers and practitioners are adopting process improvement (PI) approaches in their operations. Thus, this study aims to identify the main PI approaches implemented in EDs, as well as the benefits and barriers to implement these approaches.

Design/methodology/approach

The study is based on a rigorous systematic literature review of 115 papers. Furthermore, under the lens of thematic analysis, the authors present the descriptive and prescriptive findings.

Findings

The descriptive analysis found copious information related to PI approaches implemented in EDs, such as main PIs used in EDs, type of methodological procedures applied, as well as a set of barriers and benefits. Aiming to provide an in-depth analysis and prescriptive results, the authors carried out a thematic analysis that found underlying barriers (e.g. organisational, technical and behavioural) and benefits (e.g. for patients, the organisation and processes) of PI implementation in EDs.

Originality/value

The authors contribute to knowledge by providing a comprehensive review of the main PI methodologies applied in EDs, underscoring the most prominent ones. This study goes beyond descriptive studies that identify lists of barriers and benefits, and instead the authors categorize prescriptive elements that influence these barriers and benefits. Finally, this study raises discussions about the behavioural influence of patients and medical staff on the implementation of PI approaches.

Patient's perspective on improving the quality of acute medical care: determining patient reported outcomes

Rationale

There is an increasing societal demand for quality assurance and transparency of medical care. The American National Academy of Medicine has determined patient centredness as a quality domain for improvement of healthcare. While many of the current quality indicators are disease specific, most emergency department (ED) patients present with undifferentiated complaints. Therefore, there is a need for generic outcome measures. Our objective was to determine relevant patient reported outcomes (PROs) for quality measurement of acute care.

Methods

We conducted semistructured interviews in patients ≥18 years presenting at the ED for internal medicine. Patients with a cognitive impairment or language barrier were excluded. Interviews were analysed using qualitative content analysis.

Results

Thirty patients were interviewed. Patients reported outcomes as relevant in five domains: relief of symptoms, understanding the diagnosis, presence and understanding of the diagnostic and/or therapeutic plan, reassurance and patient experiences. Experiences were often mentioned as relevant to the perceived quality of care and appeared to influence the domain reassurance.

Conclusion

We determined five domains of relevant PROs in acute care. These domains will be used for developing generic patient reported measures for acute care. The patients’ perspective will be incorporated in these measures with the ultimate aim of organising truly patient-centred care at the ED.

The Impact of Risk Standardization on Variation in CT Use and Emergency Physician Profiling

OBJECTIVE

The purpose of this study is to use detailed electronic health record data to profile the use of condition-specific, risk-standardized imaging by emergency physicians.

MATERIALS AND METHODS

CT utilization in four emergency departments in a single health care system was retrospectively analyzed. The primary outcome for analysis was indication-specific, risk-standardized CT utilization. We constructed seven clinical cohorts on the basis of the presence or absence of a traumatic indication for the most frequently performed CT studies. Risk standardization was performed using machine learning algorithms and hierarchic logistic regression models. Variation in CT utilization for each cohort was analyzed using coefficients of variation and box plots, the effect of risk standardization on physician profiling was determined using slope diagrams and kappa values, and within-physician correlation was assessed using correlation coefficients and matrices.

RESULTS

For the seven cohorts, the number of physicians ordering more than 25 CT studies for a particular indication ranged from 70 to 88, and the number of ED visits ranged from 17,458 to 117,489. The unadjusted variation was large for each indication (coefficient of variation, 30.2-57.9). Risk standardization resulted in reduced but persistent variation for all indications (coefficient of variation, 12.3-22.3). Among indication-specific models, risk standardization resulted in reclassification by two or more deciles for 14.0-39.1% of physicians. The R value for within-physician correlation varied from 0.02 to 0.80 and was highest between chest and abdominal imaging for trauma.

CONCLUSION

In this multisite study of CT utilization, risk standardization had a substantial impact on variation in CT utilization and emergency physician profiling. Administrators and payers should include risk standardization in future measures of physician imaging to ensure valid assessment of performance and achieve improvements in emergency care value.

Interventional study to improve diabetic guidelines adherence using mobile health (m-Health) technology in Lahore, Pakistan

OBJECTIVE

To check if mobile health (m-Health) short message service (SMS) can improve the knowledge and practice of the American Diabetic Association preventive care guidelines (ADA guidelines) recommendations among physicians.

METHODOLOGY

Quasi-experimental pre-post study design with a control group.

PARTICIPANTS

The participants of the study were 62 medical officers/medical postgraduate trainees from two hospitals in Lahore, Pakistan. Pretested questionnaire was used to collect baseline information about physicians' knowledge and adherence according to the ADA guidelines. All the respondents attended 1-day workshop about the guidelines. The intervention group received regular reminders by SMS about the ADA guidelines for the next 5 months. Postintervention knowledge and practice scores of 13 variables were checked again using the same questionnaire. Statistical analysis included χ² and McNemar's tests for categorical variables and t-test for continuous variables. Pearson's correlation analysis was done to check correlation between knowledge and practice scores in the intervention group. P values of <0.05 were considered statistically significant.

RESULTS

The total number of participating physicians was 62. Fifty-three (85.5%) respondents completed the study. Composite scores within the intervention group showed statistically significant improvement in knowledge (p<0.001) and practice (p<0.001) postintervention. The overall composite scores preintervention and postintervention also showed statistically significant difference of improvement in knowledge (p=0.002) and practice (p=0.001) between non-intervention and intervention groups. Adherence to individual 13 ADA preventive care guidelines level was noted to be suboptimal at baseline. Statistically significant improvement in the intervention group was seen in the following individual variables: review of symptoms of hypoglycaemia and hyperglycaemia, eye examination, neurological examination, lipid examination, referral to ophthalmologist, and counselling about non-smoking.

CONCLUSION

m-Health technology can be a useful educational tool to help with improving knowledge and practice of diabetic guidelines. Future multicentre trials will help to scale this intervention for wider use in resource-limited countries.

How Older Adults Experience an Emergency Department Visit: Development and Validation of Measures

STUDY OBJECTIVE

This study aims to develop and validate measures of experiences of an emergency department (ED) visit suitable for use by older adults or their family members.

METHODS

A cohort of patients aged 75 years and older who were discharged home was recruited at 4 EDs. At 1 week after the visit, patients or family members were interviewed by telephone to assess problems experienced at the visit. Twenty-six questions based on 6 domains of care found in the literature were developed: 16 questions were administered to all patients; 10 questions were administered to bed patients only. Scales were developed with multiple correspondence analysis. Regression analyses were used to validate the scales, using 2 validation criteria: perceived overall quality of care and willingness to return to the same ED.

RESULTS

Four hundred twelve patients completed the 1-week interview, 197 ambulatory and 215 bed patients; family members responded for 75 patients. Two scales were developed, assessing personal care and communication (8 questions; α=.63) and waiting times (2 questions; α=.79). Both scales were significantly independently associated with perceived overall quality of care and willingness to return to the same ED.

CONCLUSION

Two scales assessing important aspects of ED care experienced by older adults are ready for further evaluation in other settings.

Comparison of Adherence to the 2013 ACC/AHA Cholesterol Guideline in a Teaching Versus Nonteaching Outpatient Clinic

BACKGROUND

Little information is available regarding prescribers' adherence rate to the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline, especially that from a teaching versus a nonteaching setting.

OBJECTIVES

We aim to evaluate adherence rates to the 2013 ACC/AHA cholesterol guideline in a teaching versus a nonteaching practice site. In addition, the impact of a pharmacist-led seminar on adherence rate to the guideline was assessed.

METHODS

This study is a 2-part retrospective chart review. Part 1 consists of patients who were initiated on statin therapy between December 2013 and November 2014. Patients were analyzed to determine if they received concordant statin therapy as recommended by the guideline. For the second part, we evaluated the impact of a seminar on the adherence rate to the guideline.

RESULTS

Of the 325 patients who received a statin prescription, 233 were included in the study. Prescriber adherence to the guideline was 42.9%, which was significantly lower than the 65.8% observed in a study previously conducted at a teaching outpatient clinic ( P < 0.0001). For the second part of our study, prescriber adherence to the guideline 3 months before the pharmacist-led seminar was 53.5%, and this adherence rate remained virtually unchanged at 54.2% at 3 months after the educational session.

CONCLUSION

The overall adherence rate to the 2013 ACC/AHA cholesterol guideline from this nonteaching outpatient clinic was significantly lower than that previously observed in a teaching outpatient clinic. The single pharmacist-led seminar did not significantly affect prescribers' adherence rate to the guideline.

Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: a Ghanaian cohort study

BACKGROUND

Guideline utilization aims at improvement in quality of care and better health outcomes. The objective of the current study was to determine the effect of provider complete adherence to the first antenatal care guidelines on the risk of maternal and neonatal complications in a low resource setting.

METHODS

Women delivering in 11 health facilities in the Greater Accra region of Ghana were recruited into a cohort study. Their first antenatal visit records were reviewed to assess providers' adherence to the guidelines, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected. Participants were followed up for 6 weeks post-partum to complete data collection on outcomes. The incidence of maternal and neonatal complications was estimated. The effects of complete adherence on risk of maternal and neonatal complications were estimated and expressed as relative risks (RRs) with their 95% confidence intervals (CI) adjusted for a potential clustering effect of health facilities.

RESULTS

Overall, 926 women were followed up to 6 weeks post-partum. Mean age (SD) of participants was 28.2 (5.4) years. Complete adherence to guidelines pertained to the care of 48.5% of women. Incidence of preterm deliveries, low birth weight, stillbirths and neonatal mortality were 5.3, 6.1, 0.4 and 1.4% respectively. Complete adherence to the guidelines decreased risk of any neonatal complication [0.72 (0.65-0.93); p = 0.01] and delivery complication [0.66 (0.44-0.99), p = 0.04].

CONCLUSION

Complete provider adherence to antenatal care guidelines at first antenatal visit influences delivery and neonatal outcomes. While there is the need to explore and understand explanatory mechanisms for these observations, programs that promote complete adherence to guidelines will improve the pregnancy outcomes.

Client Factors Affect Provider Adherence to Clinical Guidelines during First Antenatal Care

Background

The first antenatal clinic (ANC) visit helps to distinguish pregnant women who require standard care, from those with specific problems and so require special attention. There are protocols to guide care providers to provide optimal care to women during ANC. Our objectives were to determine the level of provider adherence to first antenatal visit guidelines in the Safe Motherhood Protocol (SMP), and assess patient factors that determine complete provider adherence.

Methods

This cross-sectional study is part of a cohort study that recruited women who delivered in eleven health facilities and who had utilized antenatal care services during their pregnancy in the Greater Accra region of Ghana. A record review of the first antenatal visit of participants was carried out to assess the level of adherence to the SMP, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected using a questionnaire. Percentages of adherence levels and baseline characteristics were estimated and cluster-adjusted odds ratios (OR) calculated to identify determinants.

Results

A total of 948 women who had delivered in eleven public facilities were recruited with a mean age (SD) of 28.2 (5.4) years. Overall, complete adherence to guidelines pertained to only 48.1% of pregnant women. Providers were significantly more likely to completely adhere to guidelines when caring for multiparous women [OR = 5.43 (1.69–17.44), p<0.01] but less likely to do so when attending to women with history of previous pregnancy complications [OR = 0.50 (0.33–0.75), p<0.01].

Conclusion

Complete provider adherence to first antenatal visit guidelines is low across different facility types in the Greater Accra region of Ghana and is determined by parity and history of previous pregnancy complication. Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.

Factors affecting communication in emergency departments: doctors and nurses' perceptions of communication in a trilingual ED in Hong Kong

Background

This study investigates clinicians’ views of clinician-patient and clinician-clinician communication, including key factors that prevent clinicians from achieving successful communication in a large, high-pressured trilingual Emergency Department (ED) in Hong Kong.

Methods

Researchers interviewed 28 doctors and nurses in the ED. The research employed a qualitative ethnographic approach. The interviews were audio-recorded, transcribed, translated into English and coded using the Nvivo software. The researchers examined issues in both clinician-patient and clinician-clinician communication. Through thematic analyses, they identified the factors that impede communication most significantly, as well as the relationship between these factors. This research highlights the significant communication issues and patterns in Hong Kong EDs.

Results

The clinician interviews revealed that communication in EDs is complex, nuanced and fragile. The data revealed three types of communication issues: (1) the experiential parameter (i.e. processes and procedures), (2) the interpersonal parameter (i.e. clinicians’ engagements with patients and other clinicians) and (3) contextual factors (i.e. time pressures, etc.). Within each of these areas, the specific problems were the following: compromises in knowledge transfer at key points of transition (e.g. triage, handover), inconsistencies in medical record keeping, serious pressures on clinicians (e.g. poor clinician-patient ratio and long working hours for clinicians) and a lack of focus on interpersonal skills.

Conclusions

These communication problems (experiential, interpersonal and contextual) are intertwined, creating a complex yet weak communication structure that compromises patient safety, as well as patient and clinician satisfaction. The researchers argue that hospitals should develop and implement best-practice policies and educational programmes for clinicians that focus on the following: (1) understanding the primary causes of communication problems in EDs, (2) accepting the tenets and practices of patient-centred care, (3) establishing clear and consistent knowledge transfer procedures and (4) lowering the patient-to-clinician ratio in order to create the conditions that foster successful communication. The research provides a model for future research on the relationship between communication and the quality and safety of the patient safety.

Improving emergency physician performance using audit and feedback: a systematic review

BACKGROUND

Audit and feedback can decrease variation and improve the quality of care in a variety of health care settings. There is a growing literature on audit and feedback in the emergency department (ED) setting. Because most studies have been small and not focused on a single clinical process, systematic assessment could determine the effectiveness of audit and feedback interventions in the ED and which specific characteristics improve the quality of emergency care.

OBJECTIVE

The objective of the study is to assess the effect of audit and feedback on emergency physician performance and identify features critical to success.

METHODS

We adhered to the PRISMA statement to conduct a systematic review of the literature from January 1994 to January 2014 related to audit and feedback of physicians in the ED. We searched Medline, EMBASE, PsycINFO, and PubMed databases. We included studies that were conducted in the ED and reported quantitative outcomes with interventions using both audit and feedback. For included studies, 2 reviewers independently assessed methodological quality using the validated Downs and Black checklist for nonrandomized studies. Treatment effect and heterogeneity were to be reported via meta-analysis and the I2 inconsistency index.

RESULTS

The search yielded 4332 articles, all of which underwent title review; 780 abstracts and 131 full-text articles were reviewed. Of these, 24 studies met inclusion criteria with an average Downs and Black score of 15.6 of 30 (range, 6-22). Improved performance was reported in 23 of the 24 studies. Six studies reported sufficient outcome data to conduct summary analysis. Pooled data from studies that included 41,124 patients yielded an average treatment effect among physicians of 36% (SD, 16%) with high heterogeneity (I2=83%).

CONCLUSION

The literature on audit and feedback in the ED reports positive results for interventions across numerous clinical conditions but without standardized reporting sufficient for meta-analysis. Characteristics of audit and feedback interventions that were used in a majority of studies were feedback that targeted errors of omission and that was explicit with measurable instruction and a plan for change delivered in the clinical setting greater than 1 week after the audited performance using a combination of media and types at both the individual and group levels. Future work should use standardized reporting to identify the specific aspects of audit or feedback that drive effectiveness in the ED.

Trends in mortality associated with opening of a full-capacity public emergency department at the main tertiary-level hospital in Tanzania

Background

Emergency medicine is an emerging specialty in Sub-Saharan Africa, and most hospitals do not have a fully functional emergency department (ED). We describe the mortality rates of the Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania before and after the opening of a full-capacity ED.

Methods

This retrospective study investigated ED and hospital mortality rates for patients admitted to MNH from January 2008 to January 2012. This period represents 2 years before and 2 years after the opening of the full-capacity ED in January 2010. Trained abstractors analyzed patient care logbooks, attendance registers, nurse report books, and death certificates. The January 2008 to December 2009 data are from the limited-capacity casualty room (precursor of the ED), and for February 2010 to January 2012, they are from the new ED. Data are presented as proportions or differences with 95 % confidence intervals (CIs).

Results

During the 4-year study period, the number of visits increased from 53,660 (January 2008 to December 2009) in the casualty room to 77,164 (February 2010 to January 2012) in the new ED. During this time, the overall hospital mortality rate decreased from 13.6 % (95 % CI 13.3–13.9 %) in the January 2008 to December 2009 period to 8.2 % (95 % CI 8.0–8.3 %) in the February 2010 to January 2012 period. The corresponding casualty room and ED mortality rates were 0.34 % (95 % CI 0.25–0.35 %) and 0.74 % (95 % CI 0.68–0.80 %), respectively. In the casualty room, the most commonly reported cause of death was lower respiratory tract infection and least common was poisoning. In the new ED, the most commonly reported cause of death was congestive cardiac failure and the least common was cancer.

Conclusions

The opening of a full-capacity ED in a tertiary-level hospital in sub-Saharan Africa was associated with a significant decrease in hospital mortality. This is despite a small, but significant, increase in the mortality rate in the ED as compared to that in the casualty room that it replaced.

Does a waiting room video about what to expect during an emergency department visit improve patient satisfaction?

Objective:

We created an instructional waiting room video that explained what patients should expect during their emergency department (ED) visit and sought to determine whether preparing patients using this video would 1) improve satisfaction, 2) decrease perceived waiting room times and 3) increase calls to an outpatient referral line in an ambulatory population.

Methods:

This serial cross-sectional study took place over a period of 2 months before (control) and 2 months after the introduction of an educational waiting room video that described a typical patient visit to our ED. We enrolled a convenience sample of adult patients or parents of pediatric patients who were triaged to the ED waiting room; a research assistant distributed and collected the surveys as patients were being discharged after treatment. Subjects were excluded if they were admitted. The primary outcome was overall satisfaction measured on a 5-point Likert scale, and secondary outcomes included perceived waiting room time, and the number of outpatient referral-line calls.

Results:

There were 1132 subjects surveyed: 551 prevideo and 581 postvideo. The mean age was 38 years (standard deviation [SD] 18), 61% were female and the mean ED length of stay was 5.9 hours (SD 3.6). Satisfaction scores were significantly higher postvideo, with 65% of participants ranking their visit as either “excellent” or “very good,” compared with 58.1% in the prevideo group (p = 0.019); however, perceived waiting room time was not significantly different between the groups (p = 0.24). Patient calls to our specialty outpatient clinic referral line increased from 1.5 per month (95% confidence interval [CI] 0.58–2.42) to 4.5 per month (95% CI 1.19–7.18) (p = 0.032). After adjusting for possible covariates, the most significant determinants of overall satisfaction were perceived waiting room time (odds ratio [OR] 0.41, 95% CI 0.34–0.48) and having seen the ED waiting room video (OR 1.41, 95% CI 1.06–1.86).

Conclusion:

Preparing patients for their ED experience by describing the ED process of care through a waiting room video can improve ED patient satisfaction and the knowledge of outpatient clinic resources in an ambulatory population. Future studies should research the implementation of this educational intervention in a randomized fashion.

Using Multicriteria Decision Analysis to Evaluate Patient Satisfaction in a Hospital Emergency Department

The scope of this study is to evaluate the level of patient satisfaction and to propose the solutions on how to increase the levels of satisfaction by using multicriteria analysis. A multicriteria user satisfaction analysis was used in order to measure the satisfaction and to elucidate the weak and strong points of satisfaction. The results of the questionnaire revealed that the average level of complete satisfaction is low (73.4) indicating that the citizens are somehow satisfied regarding the emergency department. Furthermore, the patients attributed great importance to the criteria of ‘processes involved in patient services’ and ‘courtesy, friendliness and professional attitude of the nurses’ in order to feel satisfied. The improvement diagram depicts that the first priority for the management committee of the hospital in order to enhance the level of satisfaction is to improve the service processes. It is obvious that the added values of the methodology are the action and improvement diagrams. By using these diagrams the management committee of the hospital can draw the future plans for improving the services of the emergency department.

Lack of association between Press Ganey emergency department patient satisfaction scores and emergency department administration of analgesic medications

STUDY OBJECTIVE

We explore the relationship between Press Ganey emergency department (ED) patient satisfaction scores and ED administration of analgesic medications, including amount of opioid analgesics received, among patients who completed a patient satisfaction survey.

METHODS

We conducted a secondary data analysis of Press Ganey ED patient satisfaction surveys from patients discharged from 2 academic, urban EDs October 2009 to September 2011. We matched survey responses to data on opioid and nonopioid analgesics administered in the ED, demographic characteristics, and temporal factors from the ED electronic medical records. We used polytomous logistic regression to compare quartiles of overall Press Ganey ED patient satisfaction scores to administration of analgesic medications, opioid analgesics, and number of morphine equivalents received. We adjusted models for demographic and hospital characteristics and temporal factors.

RESULTS

Of the 4,749 patients who returned surveys, 48.5% received analgesic medications, and 29.6% received opioid analgesics during their ED visit. Mean overall Press Ganey ED patient satisfaction scores for patients receiving either analgesic medications or opioid analgesics were lower than for those who did not receive these medications. In the univariable polytomous logistic regression analysis, receipt of analgesic medications, opioid analgesics, and a greater number of morphine equivalents were associated with lower overall scores. However, in the multivariable analysis, receipt of analgesic medications or opioid analgesics was not associated with overall scores, and receipt of greater morphine equivalents was inconsistently associated with lower overall scores.

CONCLUSION

Overall Press Ganey ED patient satisfaction scores were not primarily based on in-ED receipt of analgesic medications or opioid analgesics; other factors appear to be more important.

Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals

OBJECTIVE

Regulatory bodies and insurers evaluate hospital quality using obstetrical outcomes, however meaningful comparisons should take preexisting patient characteristics into account. Furthermore, if risk-adjusted outcomes are consistent within a hospital, fewer measures and resources would be needed to assess obstetrical quality. Our objective was to establish risk-adjusted models for 5 obstetric outcomes and assess hospital performance across these outcomes.

STUDY DESIGN

We studied a cohort of 115,502 women and their neonates born in 25 hospitals in the United States from March 2008 through February 2011. Hospitals were ranked according to their unadjusted and risk-adjusted frequency of venous thromboembolism, postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite neonatal adverse outcome. Correlations between hospital risk-adjusted outcome frequencies were assessed.

RESULTS

Venous thromboembolism occurred too infrequently (0.03%; 95% confidence interval [CI], 0.02-0.04%) for meaningful assessment. Other outcomes occurred frequently enough for assessment (postpartum hemorrhage, 2.29%; 95% CI, 2.20-2.38, peripartum infection, 5.06%; 95% CI, 4.93-5.19, severe perineal laceration at spontaneous vaginal delivery, 2.16%; 95% CI, 2.06-2.27, neonatal composite, 2.73%; 95% CI, 2.63-2.84). Although there was high concordance between unadjusted and adjusted hospital rankings, several individual hospitals had an adjusted rank that was substantially different (as much as 12 rank tiers) than their unadjusted rank. None of the correlations between hospital-adjusted outcome frequencies was significant. For example, the hospital with the lowest adjusted frequency of peripartum infection had the highest adjusted frequency of severe perineal laceration.

CONCLUSION

Evaluations based on a single risk-adjusted outcome cannot be generalized to overall hospital obstetric performance.

The Consumer Quality Index in an accident and emergency department: internal consistency, validity and discriminative capacity

BACKGROUND

Patients' experiences are an indicator of health-care performance in the accident and emergency department (A&E). The Consumer Quality Index for the Accident and Emergency department (CQI A&E), a questionnaire to assess the quality of care as experienced by patients, was investigated. The internal consistency, construct validity and discriminative capacity of the questionnaire were examined.

METHODS

In the Netherlands, twenty-one A&Es participated in a cross-sectional survey, covering 4883 patients. The questionnaire consisted of 78 questions. Principal components analysis determined underlying domains. Internal consistency was determined by Cronbach's alpha coefficients, construct validity by Pearson's correlation coefficients and the discriminative capacity by intraclass correlation coefficients and reliability of A&E-level mean scores (G-coefficient).

RESULTS

Seven quality domains emerged from the principal components analysis: information before treatment, timeliness, attitude of health-care professionals, professionalism of received care, information during treatment, environment and facilities, and discharge management. Domains were internally consistent (range: 0.67-0.84). Five domains and the 'global quality rating' had the capacity to discriminate among A&Es (significant intraclass correlation coefficient). Four domains and the 'global quality rating' were close to or above the threshold for reliably demonstrating differences among A&Es. The patients' experiences score on the domain timeliness showed the largest range between the worst- and best-performing A&E.

CONCLUSIONS

The CQI A&E is a validated survey to measure health-care performance in the A&E from patients' perspective. Five domains regarding quality of care aspects and the 'global quality rating' had the capacity to discriminate among A&Es.

Variation in resource utilization across a national sample of pediatric emergency departments

OBJECTIVE

To describe variations in emergency department (ED) quality measures and determine the association between ED costs and outcomes for 3 pediatric conditions: asthma, gastroenteritis, and simple febrile seizure.

STUDY DESIGN

This cross-sectional analysis of ED visits used the Pediatric Health Information System database. Children aged ≤ 18 years who were evaluated in an ED between July 2009 and June 2011 and had a discharge diagnosis of asthma, gastroenteritis, or simple febrile seizure were included. Two quality of care metrics were evaluated for each target condition, and Spearman correlation was applied to evaluate the relationship between ED costs (reflecting overall resource utilization) and admission and revisit rates among institutions.

RESULTS

More than 250,000 ED visits at 21 member hospitals were analyzed. Among children with asthma, the median rate of chest radiography utilization was 35.1% (IQR, 31.3%-41.7%), and that of corticosteroid administration was 82.6% (IQR, 78.5%-86.5%). For children with gastroenteritis, the median rate of ondansetron administration was 52% (IQR, 43.2%-57.0%), and that of intravenous fluid administration was 18.1% (IQR, 15.3%-21.3%). Among children with febrile seizures, the median rate of computed tomography utilization was 3.1% (IQR, 2.7%-4.3%), and that of lumbar puncture was 4.0% (IQR, 2.3%-5.6%). Increased costs were not associated with lower admission rate or 3-day ED revisit rate for the 3 conditions.

CONCLUSION

We observed variation in quality measures for patients presenting to pediatric EDs with common conditions. Higher costs were not associated with lower hospitalization or ED revisit rates.

The influence of evidence in the surgical treatment of thumb basilar joint arthritis

BACKGROUND

For surgical treatment of thumb carpometacarpal joint arthritis, current evidence suggests that simple trapeziectomy is as effective as and may be safer than trapeziectomy and ligament reconstruction with or without tendon interposition. The authors examined whether current practice patterns in the surgical treatment of thumb carpometacarpal joint arthritis reflect adoption of simple trapeziectomy as best practice, and investigated whether surgeon preferences and third-party payer patterns are associated with use of simple trapeziectomy.

METHODS

The authors performed a retrospective cross-sectional study of 6776 surgical treatments for thumb carpometacarpal joint arthritis using the all-payer State Ambulatory Surgery Database for Florida, from 2006 to 2009. Multinomial regression analysis was applied to examine associations between covariates, describing surgeon and third-party payer factors and type of procedure performed. An intraclass correlation coefficient was calculated to determine how much of the difference in patient outcome (procedure type) is attributable to differences between surgeons.

RESULTS

Across surgeon characteristics included in the analysis, patients' outcome probabilities were over 90 percent in favor of treatment with trapeziectomy and ligament reconstruction with or without tendon interposition. The level of intraclass correlation among patients clustered within a surgeon showed that individual surgeons contribute substantially to determining what procedure type a patient undergoes.

CONCLUSIONS

In this multiyear, one-state study, current evidence demonstrating the equivalent effectiveness of simple trapeziectomy compared with more involved alternatives did not result in wide adoption of the technique. This finding is consistent with studies in many clinical disciplines that highlight the difficulty of influencing clinical practice with available evidence.

Developing an evaluation framework for consumer-centred collaborative care of depression using input from stakeholders

OBJECTIVE

To develop a framework for research and evaluation of collaborative mental health care for depression, which includes attributes or domains of care that are important to consumers.

METHODS

A literature review on collaborative mental health care for depression was completed and used to guide discussion at an interactive workshop with pan-Canadian participants comprising people treated for depression with collaborative mental health care, as well as their family members; primary care and mental health practitioners; decision makers; and researchers. Thematic analysis of qualitative data from the workshop identified key attributes of collaborative care that are important to consumers and family members, as well as factors that may contribute to improved consumer experiences.

RESULTS

The workshop identified an overarching theme of partnership between consumers and practitioners involved in collaborative care. Eight attributes of collaborative care were considered to be essential or very important to consumers and family members: respectfulness; involvement of consumers in treatment decisions; accessibility; provision of information; coordination; whole-person care; responsiveness to changing needs; and comprehensiveness. Three inter-related groups of factors may affect the consumer experience of collaborative care, namely, organizational aspects of care; consumer characteristics and personal resources; and community resources.

CONCLUSION

A preliminary evaluation framework was developed and is presented here to guide further evaluation and research on consumer-centred collaborative mental health care for depression.

Determinants of patient satisfaction in an Australian emergency department fast-track setting

OBJECTIVES

To describe the relationship between waiting time and patient satisfaction, and to determine predictors of overall care rating in an emergency department (ED) fast-track setting.

METHODS

A convenience sample of patients triaged to a fast-track unit were surveyed. Patient satisfaction was scored using a validated survey instrument, as well as a single overall care rating (poor to excellent). Median satisfaction scores were compared between each incremental hour of waiting time. Bivariate analysis was conducted between those who waited 1 h or less, and those who waited longer. Ordered logistic regression was used to determine predictors of improved overall care rating.

RESULTS

236 patients completed surveys (response rate of 74%). Of these, 84% rated their care as either very good or excellent. There was a linear decrease in median satisfaction scores for each incremental hour of waiting time associated with half the odds of higher overall care rating after adjusting for presenting problem type, triage category, and treating clinician type (OR 0.53 95% CI 0.37 to 0.75 p<0.001). English language (OR 2.43 95% CI 1.33 to 4.42 p=0.004) and initial consultation by a nurse practitioner (NP) (OR 1.81 95% CI 1.03 to 3.31 p=0.038) were also found to be significant predictors of improved overall care rating.

CONCLUSIONS

Waiting time was found to be highly predictive of patient satisfaction in an emergency fast-track unit with English language and NPs also associated with improved overall care rating. Future measures to improve patient satisfaction in fast-track units should focus on these factors.

Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors

AIMS

This paper is a report of a study of quality of care delivered by an emergency department fast track unit where both doctors and an emergency nurse practitioner treated patients.

BACKGROUND

Fast track units were established in Australian emergency departments to meet the needs of low complexity emergency department patients. Few studies have reported on the overall quality of care delivered by these units.

METHODS

A convenience sample of adult patients triaged to an Australian emergency department fast track unit between April 2010 and April 2011 were randomised to care by a doctor or an emergency nurse practitioner. Quality of care was measured using patient satisfaction, follow up health status using Short Form 12 and adverse event rate (missed fractures or unplanned representations).

RESULTS

A total of 320 patients were enrolled into the study. Of the 236 patients who submitted completed survey forms, median satisfaction scores were 22 out of 25 with 84% of patients rating care as "excellent" or "very good". At two week follow up, health status score was comparable to normal healthy populations. When comparing study groups, patient satisfaction scores were significantly higher in the ENP group compared to DR group.

CONCLUSIONS

Patients received high quality of care in this fast track unit where both nurse practitioner and doctors treated patients. Emergency nurse practitioners were associated with higher patient satisfaction.

A consensus-based process to define standard national data elements for a Canadian emergency department information system

Canadian hospitals gather few emergency department (ED) data, and most cannot track their case mix, care processes, utilization or outcomes. A standard national ED data set would enhance clinical care, quality improvement and research at a local, regional and national level. The Canadian Association of Emergency Physicians, the National Emergency Nurses Affiliation and l'Association des médecins d'urgence du Québec established a joint working group whose objective was to develop a standard national ED data set that meets the information needs of Canadian EDs. The working group reviewed data elements derived from Australia's Victorian Emergency Minimum Dataset, the US Data Elements for Emergency Department Systems document, the Ontario Hospital Emergency Department Working Group data set and the Canadian Institute for Health Information's National Ambulatory Care Reporting System data set. By consensus, the group defined each element as mandatory, preferred or optional, and modified data definitions to increase their relevance to the ED context. The working group identified 69 mandatory elements, 5 preferred elements and 29 optional elements representing demographic, process, clinical and utilization measures. The Canadian Emergency Department Information System data set is a feasible, relevant ED data set developed by emergency physicians and nurses and tailored to the needs of Canadian EDs. If widely adopted, it represents an important step toward a national ED information system that will enable regional, provincial and national comparisons and enhance clinical care, quality improvement and research applications in both rural and urban settings.

A Mixed-Methods Study of the Quality of Care Provided to Patients Boarding in the Emergency Department

Concern exists regarding care patients receive while boarding (staying in the emergency department [ED] after a decision to admit has been made). This exploratory study compares care for such ED patients under “Inpatient Responsibility” (IPR) and “ED Responsibility” (EDR) models using mixed methods. The authors abstracted quantitative data from 1,431 patient charts for ED patients admitted to two academic hospitals in 2004-2005 and interviewed 10 providers for qualitative data. The authors compared delays using logistic regression and used provider interviews to explore reasons for quantitative findings. EDR patients had more delays to receiving home medications over the first 26 hours of admission but fewer while boarding; EDR patients had fewer delayed cardiac enzymes checks. Interviews revealed that culture, resource prioritization, and systems issues made care for boarded patients challenging. A theoretically better responsibility model may not deliver better care to boarded patients because of cultural, resource prioritization, and systems issues.

The elder-friendly emergency department assessment tool: development of a quality assessment tool for emergency department-based geriatric care

OBJECTIVES

To develop and conduct a preliminary validation of selected subscales of an elder-friendly emergency department (ED) assessment tool.

DESIGN

Content validation of tool by an international panel. Construct validation using care ratings of ED lead physicians and nurses.

SETTING

Quebec, Canada.

PARTICIPANTS

The international panel comprised 34 clinicians, administrators, and researchers. The construct validation was based on a 2006 survey of ED lead physicians and nurses at all 103 EDs in the province, of whom 68 (66%) supplied complete data.

MEASUREMENTS

The initial tool included five subscales: ED staffing, screening and assessment, discharge planning, community services, and care philosophy. Differences in subscale scores were examined according to ED size, and of these scores were correlated with care ratings made by lead physicians and nurses.

RESULTS

The average scores for three subscales (ED staffing, discharge planning, and community services) varied according to ED size. After adjustment for ED size, three subscales (screening and assessment, discharge planning, and community services) were correlated with ED nurse or physician care ratings. A preliminary tool, taking into account all factors, is proposed.

CONCLUSION

This study provides preliminary evidence of the validity of three subscales of the proposed elder-friendly ED assessment tool. Results suggest that ED size should be considered in interpreting these subscales. Further evaluation and validation of the proposed tool will be needed to further its utility in helping to focus the quality improvement efforts of clinicians, managers, and administrators related to the care they provide older adults.

Emergency department crowding and risk of preventable medical errors

The objective of the study is to determine the association between emergency department (ED) crowding and preventable medical errors (PME). This was a retrospective cohort study of 533 ED patients enrolled in the National ED Safety Study (NEDSS) in four Massachusetts EDs. Individual patients' average exposure to ED crowding during their ED visit was compared with the occurrence of a PME (yes/no) for the three diagnostic categories in NEDSS: acute myocardial infarction, asthma exacerbation, and dislocation requiring procedural sedation. To accommodate site-to-site differences in available administrative data, ED crowding was measured using one of three previously validated crowding metrics (ED Work Index, ED Workscore, and ED Occupancy). At each site, the continuous measure was placed into site-specific quartiles, and these quartiles then were combined across sites. We found that 46 (8.6%; 95% confidence interval, 6.4-11.3%) of the 533 patients experienced a PME. For those seen during higher levels of ED crowding (quartile 4 vs. quartile 1), the occurrence of PMEs was more than twofold higher, both on unadjusted analysis and adjusting for two potential confounders (diagnosis, site). The association appeared non-linear, with most PMEs occurring at the highest crowding level. We identified a direct association between high levels of ED crowding and risk of preventable medical errors. Further study is needed to determine the generalizability of these results. Should such research confirm our findings, we would suggest that mitigating ED crowding may reduce the occurrence of preventable medical errors.

An empirical assessment of boarding and quality of care: delays in care among chest pain, pneumonia, and cellulitis patients

BACKGROUND

As hospital crowding has increased, more patients have ended up boarding in the emergency department (ED) awaiting their inpatient beds. To the best of our knowledge, no study has compared the quality of care of boarded and nonboarded patients.

OBJECTIVES

This study sought to examine whether being a boarded patient and boarding longer were associated with more delays, medication errors, and adverse events among ED patients admitted with chest pain, pneumonia, or cellulitis.

METHODS

This study was a retrospective cohort design in which data collection was accomplished via medical record review from two urban teaching hospitals. Patients admitted with chest pain, pneumonia, or cellulitis between August 2004 and January 2005 were eligible for inclusion. Our outcomes measures were: 1) delays in administration of home medications, cardiac enzyme tests, partial thromboplastin time (PTT), and antibiotics; 2) medication errors; and 3) adverse events or near misses. Primary independent variables were boarded status, boarding time, and boarded time interval. Multiple logistic regression models controlling for patient, ED, and hospital characteristics were used.

RESULTS

A total of 1,431 patient charts were included: 811 with chest pain, 387 with pneumonia, and 233 with cellulitis. Boarding time was associated with an increased odds of home medication delays (adjusted odds ratio [AOR] = 1.07, 95% confidence interval [CI] = 1.05 to 1.10), as were boarded time intervals of 12, 18, and 24 hours. Boarding time also was associated with lower odds of having a late cardiac enzyme test (AOR = 0.93, 95% CI = 0.88 to 0.97).

CONCLUSIONS

Boarding was associated with home medication delays, but fewer cardiac enzyme test delays. Boarding was not associated with delayed PTT checks, antibiotic administration, medication errors, or adverse events/near misses. These findings likely reflect the inherent resources of the ED and the inpatient units.

The correlation between patient comprehension of their reason for hospital admission and overall patient satisfaction in the emergency department

OBJECTIVES

(1) To determine the patient's comprehension of the reasons for admission in the emergency department and (2) to examine what, if any, correlation there is between patients' understanding and satisfaction with care.

METHODS

Using a convenience sample over a 6-month period, patients from an urban, level 1 adult and pediatric trauma center were interviewed by research fellows in a patient care area. A total of 287 patients were given the Emergency Department Quality Study (EDQS) survey in either English or Spanish. Only patients 18 years or older, who were able to consent, spoke English or Spanish, and were medically stable were included in the study. The study was approved by the institutional review board. An analysis of variance was used to determine if any significant difference exists between patient understanding and satisfaction with care. In order to determine which of these variables could predict patient satisfaction levels, a log linear regression was used.

RESULTS

The majority (90%) of patients rated their care as good to excellent, and 78% of them did understand why they were being admitted. A total of 22%, however, did not understand their test results and the cause for their being admitted to the hospital. There was a significant negative finding among the patient not having an understanding of tests, reason for admission, returning to the emergency department for care, and their overall patient satisfaction.

CONCLUSIONS

Successful communication between doctors and patients around the reasons for admission and test results can be an important predictor of patient satisfaction. Medical information not communicated in an understandable way to patients can lead to lower levels of patient satisfaction.

Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital

OBJECTIVES

Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital.

METHODS

This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information.

RESULTS

Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent.

CONCLUSIONS

Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

Benchmarks for the emergency department care of children with asthma, bronchiolitis, and croup

OBJECTIVES

The objectives of this study were (1) to measure the 2005 performance of freestanding children's hospital emergency departments (EDs) in the care of children with asthma, bronchiolitis, and croup (ABC) using 5 clinical quality indicators and (2) to construct achievable benchmarks for 7 clinical quality indicators of ED care for children with ABC for 2005.

METHODS

This was a retrospective review using the Pediatric Health Information System database containing information on 1,468,607 (2005) discharges. Performance on 5 established clinical quality indicators for ABC was determined in patients younger than 19 years at 27 hospital EDs in the United States. Benchmarks were computed for 7 clinical quality indicators.

RESULTS

Corticosteroids were administered in 65.8% (95% confidence interval [CI], 65.2%-66.2%) of visits for moderate to severe asthma and in 82.5% (95% CI, 82.0%-83.0%) of visits for croup. Physicians ordered an x-ray in 28.6% (95% CI, 28.1%-29.0%) of asthma visits, 37.3% (95% CI, 36.7%-37.9%) of bronchiolitis visits, and in 9.1% (95% CI, 8.7%-9.5%) of croup visits. Benchmarks for corticosteroid administration were 79% and 92% for asthma and croup, respectively; benchmarks for ordering x-rays were 17% for both asthma and bronchiolitis and 2% for croup. Additional benchmarks for antibiotic administration in the ED for asthma and bronchiolitis were 1% and 2%, respectively.

CONCLUSIONS

Variation exists among freestanding children's hospitals in the ED care for ABC, but the performance is better than previously reported national averages. We report achievable benchmarks for ED care based on objective clinical quality indicators.

Safety issues and concerns for the neurological patient in the emergency department

INTRODUCTION

Patient safety in our medical system has been an increasing national concern. Neurological patient safety in the emergency department (ED) has not been studied. The purpose of this article is thus to describe the issues relevant to neurological patient safety in the ED, review the current status of the literature, identify specific patient populations at risk, and suggest applicable solutions.

METHODS

Medline and PubMed literature review of key words associated with patient safety, neurological diseases, and EDs.

RESULTS

Little data can be found on overall neurological patient safety in the ED, however data for specific neurological emergencies including subarachnoid hemorrhage, stroke, status epilepticus, and head and spine trauma does exist and is reviewed.

CONCLUSIONS

Limitations in ED education and access to neurological expertise may place some patients at risk. Recommendations for improving neurological patient safety in the EDs are suggested and include a discussion on barriers to implementation.

Clinical impact of the use of additional ultrasonography in diagnostic breast imaging

The degree of adherence with evidence-based guidelines for the use of breast ultrasonography was determined in clinical practice of radiologists in six hospitals. Additional ultrasonography was performed in 2,272 (53%) of all 4,257 patients referred for mammography. High adherence rates (mean: 95%) were observed for guidelines recommending ultrasonography in patients referred for palpable breast masses and abnormal screening and diagnostic mammograms. Lower adherence rates (mean: 81%, Pearson correlation coefficient= -0.57; p=0.001) were found for guidelines advising against additional ultrasonography in patients referred for breast symptoms, a known benign abnormality, a family history or anxiety of breast cancer. The overuse of ultrasonography in 442 patients and underuse in 95 patients led to five additional false-positive results. It was concluded that the guidelines seem workable and feasible in clinical practice and that the current daily routine of diagnostic breast imaging corresponded to a great extent to the guidelines proposed.

The National Emergency Department Safety Study: study rationale and design

The significance of medical errors is widely appreciated. Given the frequency and significance of errors in medicine, it is important to learn how to reduce their frequency; however, the identification of factors that increase the likelihood of errors poses a considerable challenge. The National Emergency Department Safety Study (NEDSS) sought to characterize organizational- and clinician-associated factors related to the likelihood of errors occurring in emergency departments (EDs). NEDSS was a large multicenter study coordinated by the Emergency Medicine Network (EMNet; www.emnet-usa.org). It was designed to determine if reports by ED personnel about safety processes are significantly correlated with the actual occurrence of errors in EDs. If so, staff reports can be used to accurately identify processes for safety improvements. Staff perceptions were assessed with a survey, while errors were assessed through chart review of three conditions: acute myocardial infarction, acute asthma, and reductions of dislocations under procedural sedation. NEDSS also examined the characteristics of EDs associated with the occurrence of errors. NEDSS is the first comprehensive national study of the frequency and types of medical errors in EDs. This article describes the methods used to develop and implement the study.

Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument

OBJECTIVES

Patient complaints to the emergency department (ED) have been well studied as indicators of quality. However, no study of complaints from healthcare providers (physicians, nurses and hospital administrators) has been published. Given their experience and expertise, healthcare providers are uniquely positioned to provide informed opinions about patient care. We present 1 year's results from a system initiated to capture healthcare providers' complaints, respond systematically, and integrate them into our quality program.

METHODS

Complaints by healthcare providers to the ED for calendar year 2002 generated a "Care Concern" addressed by the involved emergency physician within 7 days. These were reviewed by two quality managers who assigned one of eight categories to the primary complaint and evaluated the need for formal peer review.

RESULTS

Of 185 complaints, 53 (29%) were from healthcare providers. Of these, 31 (58%) related to medical care: 8 (15%) to diagnostic work-up, 9 (16%) to ED management, and 14 (26%) to consultations. Eleven (21%) related to miscommunication: 7 (13%) to disposition and 4 (8%) concerned infraction of hospital policy. Ten (19%) led to further formal review with two resulting in changes in ED policy.

CONCLUSION

Healthcare workers' complaints highlight an aspect of customer care that is sometimes overlooked-that which we provide to other services. The complaints relate primarily to patient care issues, frequently raising concerns requiring intervention. This underused source of information presents a potential wealth of opportunity for quality improvement and customer service in the ED.

Coded Chief Complaints--automated analysis of free-text complaints

OBJECTIVES

To describe a new chief-complaint categorization schema, the development of a computer text-parsing algorithm to automatically classify free-text chief complaints into this schema, and use of these coded chief complaints to describe the case mix of a community emergency department (ED).

METHODS

Coded Chief Complaints for Emergency Department Systems (CCC-EDS) is a new and untested schema of 228 chief complaints, grouped within dimensions of type and system. A computerized text-parsing algorithm for automatically reading and classifying free-text chief complaints into 1 of these 228 coded chief complaints was developed by using a consecutive derivation sample of 46,602 patients who presented to a community teaching-hospital ED in 2004. Descriptive statistics included frequency of patients presenting with the 228 coded chief complaints; percentage of free-text complaints not categorizable by the CCC-EDS; and admission rate, age, and gender differences by chief complaint.

RESULTS

In the derivation sample, the text-parsing algorithm classified 87.5% of 45,329 ED visits with non-null free-text chief complaints into 1 of 194 coded chief complaints. The text-parsing algorithm successfully classified 87.3% of the free-text chief complaints in a validation sample. The five most common coded chief complaints were Abdominal Pain (3,734 visits), Fever (2,234), Chest Pain (2,183), Breathing Difficulty (2,030), and Cuts-Lacerations (2,028).

CONCLUSIONS

The CCC-EDS is a new comprehensive, granular, and useful classification schema for categorizing chief complaints in an ED. A CCC-EDS text-parsing algorithm successfully classified the majority of free-text chief complaints from an ED computer log. These coded chief complaints were used to describe the case mix of a community teaching-hospital ED.

The use of performance improvement methods to enhance emergency department patient satisfaction in the United States: a critical review of the literature and suggestions for future research

OBJECTIVES

The authors reviewed the evidence on performance improvement methods for increasing emergency department (ED) patient satisfaction to provide evidence-based suggestions for clinical practice.

METHODS

Data sources consisted of searches through MEDLINE, CINAHL, PSYCHINFO, Cochrane Library, and Emergency Medicine Abstracts and a manual search of references. Articles were included if they reported a performance improvement intervention targeting patient satisfaction in the ED setting. Articles on studies not conducted in the United States or that failed to provide enough details to allow critical evaluation of the study were excluded. Two authors used structured evaluation criteria to independently review each retained study.

RESULTS

Nineteen articles met all selection criteria. Three studies found varying levels of support for multicomponent interventions, predominantly focused on implementation of clinical practice guidelines for specific presenting complaints and process redesign. Sixteen studies evaluated single-component interventions, with the following having at least one supportive study: using alternating patient assignment to provider teams rather than "zone"-based assignment, enhancing provider communication and customer service skills, incorporating information delivery interventions (e.g., pamphlets, video) that target patient expectations, using preformatted charts, and establishing ED-based observation units for specific conditions such as asthma and chest pain.

CONCLUSIONS

There is modest evidence supporting a range of performance improvement interventions for improving ED patient satisfaction. Further work is needed before specific, evidence-based recommendations can be made regarding which process changes are most effective. Recommendations are made for improving the quality of performance improvement efforts in the ED setting.

Biomedical informatics applications for asthma care: a systematic review

Asthma is a common condition associated with significant patient morbidity and health care costs. Although widely accepted evidence-based guidelines for asthma management exist, unnecessary variation in patient care remains. Application of biomedical informatics techniques is one potential way to improve care for asthmatic patients. We performed a systematic literature review to identify computerized applications for clinical asthma care. Studies were evaluated for their clinical domain, developmental stage and study design. Additionally, prospective trials were identified and analyzed for potential study biases, study effects, and clinical study characteristics. Sixty-four papers were selected for review. Publications described asthma detection or diagnosis (18 papers), asthma monitoring or prevention (13 papers), patient education (13 papers), and asthma guidelines or therapy (20 papers). The majority of publications described projects in early stages of development or with non-prospective study designs. Twenty-one prospective trials were identified, which evaluated both clinical and non-clinical impacts on patient care. Most studies took place in the outpatient clinic environment, with minimal study of the emergency department or inpatient settings. Few studies demonstrated evidence of computerized applications improving clinical outcomes. Further research is needed to prospectively evaluate the impact of using biomedical informatics to improve care of asthmatic patients.

Review of the literature on survey instruments used to collect data on hospital patients' perceptions of care

OBJECTIVE

To review the existing literature (1980-2003) on survey instruments used to collect data on patients' perceptions of hospital care.

STUDY DESIGN

Eight literature databases were searched (PubMED, MEDLINE Pro, MEDSCAPE, MEDLINEplus, MDX Health, CINAHL, ERIC, and JSTOR). We undertook 51 searches with each of the eight databases, for a total of 408 searches. The abstracts for each of the identified publications were examined to determine their applicability for review.

METHODS OF ANALYSIS

For each instrument used to collect information on patient perceptions of hospital care we provide descriptive information, instrument content, implementation characteristics, and psychometric performance characteristics.

PRINCIPAL FINDINGS

The number of institutional settings and patients used in evaluating patient perceptions of hospital care varied greatly. The majority of survey instruments were administered by mail. Response rates varied widely from very low to relatively high. Most studies provided limited information on the psychometric properties of the instruments.

CONCLUSIONS

Our review reveals a diversity of survey instruments used in assessing patient perceptions of hospital care. We conclude that it would be beneficial to use a standardized survey instrument, along with standardization of the sampling, administration protocol, and mode of administration.

The promises and pitfalls of evidence-based medicine

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. While advocates welcome the stronger scientific foundation of such guidelines, critics fear that they will lead to "cookbook medicine." Studies show, however, that few guidelines lead to consistent changes in provider behavior. The hopes, fears, and mixed record of EBM are rooted in the traditional professional perspective of the clinician as sole decisionmaker. Multifaceted implementation strategies that take the collaborative nature of medical work into consideration promise more effective changes in clinical practice.

Analysis of complaints lodged by patients attending Victorian hospitals, 1997–2001

OBJECTIVE

To describe complaints by patients and compare rates of complaint in demographic subgroups of patients and hospital departments.

DESIGN AND SETTING

Retrospective analysis of complaints made by patients attending 67 hospitals (metropolitan, 25; rural, 42) in Victoria, and lodged with the Victorian Health Complaint Information Program (January 1997 - December 2001).

MAIN OUTCOME MEASURES

Demographic characteristics of patients lodging complaints and the hospital department involved; nature and outcome of complaints.

RESULTS

From a total of over 13 million patients presenting to hospital during the study period, 19 156 patients or their representatives (mostly their parents, children or spouses) lodged 26 785 "issues" of complaint (overall complaint rate, 1.42 complaints/1000 patients). Significantly more complaints (P < 0.001) were lodged by (or on behalf of) female patients (complaint rate ratio, 1.3; 95% CI, 1.2-1.3), public patients (rate ratio, 2.1; 95% CI, 2.0-2.2) and Australian-born patients (rate ratio, 8.9; 95% CI, 8.3-9.6). The complaint rate for general wards was 6.2/1000 patients (95% CI, 6.1-6.3). Intensive care units had a similar rate of 5.9/1000 (95% CI, 5.4-6.5), but aged-care departments had a significantly higher rate of 45.2/1000 (95% CI, 39.5-51.7), while emergency departments (1.9/1000; 95% CI, 1.8-2.0), operating theatres (1.0/1000; 95% CI, 1.0-1.1), day-procedure units (0.5/1000; 95% CI, 0.5-0.6) and outpatient departments (0.4/1000; 95% CI, 0.4-0.4) had significantly lower rates. Complaints relating to communication (poor attention, discourtesy, rudeness), access to healthcare (no/inadequate service, treatment delays) and treatment (inadequate treatment and nursing care) accounted for 29.2%, 28.5% and 22.5% of complaints, respectively. Most (84.5%) complaints were resolved. Apologies or explanations resolved 27.8% and 27.5% of complaints, respectively.

CONCLUSION

Interventions to decrease the number of complaints in the areas of communication and access to healthcare need to be implemented. The active use of complaint data for quality-improvement activities is recommended.